Observational Study of Ultrasound-Assisted Liposuction for Lower Limb Lipedema on 191 Female Patients.

Patients included in this cohort were admitted between January of 2021 and December of 2023. Patients who presented for a plastic surgery consultation for a request for lower limb lipedema disorder treatment were included in the cohort. Inclusion criteria of the cohort were as follows: older than 18 years, lower limb lipedema disorder stage 1 to 3, 10 and type 3 lipedema (lower limb localization 10 , 23 ). The diagnosis of lipedema was affirmed by a specialized angiologist during a dedicated consultation. This thorough assessment encompassed a clinical examination; Doppler ultrasonography of the lower limb; and lymphoscintigraphy, which confirmed the diagnosis while excluding other vascular and lymphatic disorders of the lower limbs. The staging of lipedema used in the study was derived from the classification outlined in Table 1 . 30 Lipedema Staging Classification Every patient had completed a 6-month conservative treatment regimen without symptom improvement, involving weight management, use of compression garments (class 3 round-knitted pantyhose), CDT, physical therapy, exercise routines, dietary adjustments, and psychological counseling. All skin types are represented in the study. The CDT protocol was as follows: patients underwent manual therapy sessions twice per week, each lasting at least 30 minutes. In addition, sequential pneumatic compression pumps were used under the supervision of a physiotherapist at least once per week. Regular exercise, including aqua bicycling, was strongly recommended 3 times weekly, combined with muscle strengthening and daily walking. 31 Patients were also advised to wear flat-knit compression tights as much as possible for 6 months. 32 The primary goals of conservative therapy were to alleviate pain, improve comfort and mobility, and reduce edema. According to the 2021 Consensus Document on Lipedema, surgical treatment is recommended for patients who do not experience sufficient improvement with conservative measures. 31 Patients were excluded from the cohort if they had a body mass index (BMI) exceeding 32 kg/m 2 , hemoglobin levels below 12 g/dL, were active smokers, presented any contraindication to general anesthesia, or had venous thrombosis or phlebopathology requiring vascular treatment. In patients with hemoglobin levels at or below 12 g/dL, massive liposuction carries several risks, primarily attributable to reduced oxygen-carrying capacity and an elevated risk of bleeding. Commonly cited complications in the literature include increased bleeding, anemia, hypovolemic shock, respiratory complications, infection, and prolonged recovery. 33 , 35 – 37 All liposuctions were performed as inpatient procedures under general anesthesia for patient comfort. Ferritin levels were monitored before surgery, and intravenous iron supplementation was given if needed. Hemoglobin levels were required to exceed 12 g/dL for surgery. A lower limb angiologic check-up was conducted before each procedure. Patients underwent 2 operations spaced 6 months apart. The first involved circular lymphatic-sparing UAL liposuction of the legs, targeting the ankles, calves, and knees, whereas the second focused on the thighs and saddlebags. This 2-stage approach is recommended for substantial fat removal in lipedema type III. Literature advises not exceeding 5 liters of fat removal per session, with some studies suggesting up to 7 liters may be safe. 34 , 35 We chose this method to keep fat removal below 10% of the patient’s body weight, or 7 liters, in line with expert guidelines. 36 An alternative approach could involve treating the anterior and posterior portions in separate operations, but we opted for legs first for cosmetic reasons. WAL and TAL are well described in lipedema treatment. 20 – 22 , 37 – 40 WAL uses a water jet to minimize tissue trauma and bleeding, enhancing recovery, whereas TAL involves injecting a tumescent solution of saline, local anesthetic, and vasoconstrictors to numb the area and reduce blood loss. Perioperative prophylactic antibiotics (cephalosporin) were given as a single dose, along with 1 g of tranexamic acid intravenously 30 minutes before surgery. Intravenous hydration was maintained with crystalloids at 10 to 12 mL/kg over 24 hours, and hemoglobin levels were monitored intraoperatively and on the first 2 postoperative days. Initially, patients were positioned prone, then repositioned supine. Consistency was ensured by having the same senior surgeon (B.H.) for all procedures. Four incisions were made around the ankle, with an additional incision in the calf’s middle. The knee area had 4 incisions, along with incisions in the saddlebag, inferior gluteal fold, and crural region (Fig. 1 ). Silicone rings were used to prevent skin burns around the incisions (Fig. 2 ). Power-assisted tumescent infiltration was conducted using saline with adrenaline (1 mg/1 liter), followed by vibration amplification of sound energy at resonance (VASER), using small titanium probes (3.7-mm diameter) designed for lipedema (Fig. 2 ). VASER parameters included 60% energy delivery in pulsed-energy mode, maintaining peak vibration amplitudes according to guidelines (Fig. 2 ). Incision localization on the anterior ( left ) and posterior ( right ) part of the lower limb. The incisions are marked and are positioned to allow lymphatic-sparing liposuction. The VASERlipo system, an all-inclusive platform for fragmentation, emulsification, and aspiration ( left ). For lipedema, we set the machine to V pulsed-mode at 60% power ( above , right ), and use a 5-ring probe to ensure proper energy dispersion in the target tissue ( center , right ). To prevent skin burns, we use a skin port (silicone ring) ( below , right ). Ultrasound treatment lasted 1 minute per 100 mL of saline adrenaline, totaling 10 minutes for each liter of tumescent infiltration. Our approach targeted the superficial fat layer first, then the deeper layer to minimize burn risk. 24 Liposuction was performed using a 3-mm smooth cannula for the ankle, calf, knees, and inner thighs, and a 4-mm cannula for the anterior and posterior thighs and saddlebags. The lymphatic-sparing technique involved harvesting fat parallel to lymphatic vessels at a slow pace. VASER was applied first to the superficial layer, followed by the deep layer to prevent burns. After that, lipoaspiration started with the deep fat layer, moving to the superficial layer using a 3-mm cannula. At the procedure’s end, incisions were left open for fluid and lymphatic drainage; no drains were used. Open incisions can help manage fluid accumulation and reduce complications such as seroma and infection, which may enhance patient comfort and healing. 41 , 42 A compressive dressing was applied for 2 days. Postoperative instructions included starting CDT on the second day after surgery, with 2 sessions per week for 6 months. Compression garments (class 3 round-knitted pantyhose) were prescribed from 2 days after surgery and worn for 6 months. Patients were encouraged to exercise while wearing garments and keep them on as much as possible. For the first 2 days, dressings covered incision sites before switching to the garments. In addition, physical therapy, exercise regimens, and weight control measures were recommended, with swimming and aqua biking activities advised to begin 1 month after surgery. In this analysis, we examined preoperative variables including BMI, age, and the stage of lipedema. The primary outcome entailed self-assessment of pain levels before and after treatment using a visual analog scale (VAS), that incorporated a functional evaluation of the lower limb. Follow-up assessments were conducted at 12 months during a routine visit. This scale assessed 10 criteria, each ranging from 0 (indicating no pain) to 10 (indicating severe pain), including the intensity of pain in affected areas, sensitivity to touch or pressure, susceptibility to bruising, sensation of heat in the limbs, occurrence of cold legs, swelling during the day, onset of muscle cramps, feelings of leg fatigue and heaviness, difficulty in walking, and satisfaction level with appearance of the limbs. ( See Document, Supplemental Digital Content 1 , which shows the questionnaire: a self-assessment of pain levels before and after treatment using a VAS, which includes a functional evaluation of the lower limb. Follow-up assessments are conducted 12 months after the second treatment during a routine visit. The VAS evaluates 10 criteria, scoring from 0 [no pain] to 10 [severe pain], including pain intensity, sensitivity to touch, bruising tendency, limb temperature changes, swelling, muscle cramps, fatigue, heaviness, walking difficulties, and cosmetic satisfaction, https://links.lww.com/PRS/I55 .) The questionnaire was administered and completed during both the preoperative consultation and the postoperative consultation 12 months after surgical treatment as standard assessment of our surgery. The secondary endpoint evaluated in this study was the decrease in thickness of the lower limb pannus, assessed through changes in circumference at specific anatomical points: ankles, calves (proximal third at the widest point), knees (just above), thighs (medial third), and saddlebags (adjacent to the greater trochanter) (Fig. 3 ). These measurements were taken with the patient standing and feet together, both before and at the 12-month follow-up following complete surgical treatment. All circumference measurements, recorded in centimeters, were consistently conducted by the same operator. Red lines indicate the anatomical areas to be measured before and after the surgical procedure: ankles, calves (proximal third at the widest point), knees (just above), thighs (medial third), and saddlebags (adjacent to the greater trochanter). All postoperative complications were documented meticulously, encompassing changes in hemoglobin levels assessed through preoperative and postoperative blood tests conducted 2 days following surgery. The complications included seromas requiring drainage, nonnecrotizing dermohypodermitis, skin necrosis, transient hyperpigmentation, severe anemia necessitating transfusion, phlebitis, and the need for a third corrective operation. Furthermore, the total volume of lipoaspirate harvested during each liposuction procedure was recorded meticulously, along with the corresponding percentage of body weight. Additional parameters such as transfusion rates after surgery, duration of hospital stay, and the total number of operations each patient underwent were also diligently noted. Moreover, frontal, back, and right and left profile photographs were captured for each patient before the session and at the 12-month follow-up mark to document any changes in appearance over time (Fig. 4 ). Anterior ( above ) and posterior ( below ) portions of the lower limbs of a patient ( left ) before treatment and ( right ) 12 months after surgery. During the final 12-month follow-up, patients completed a satisfaction questionnaire, consisting of 5 items rated on a Likert scale, to assess their overall satisfaction with the aesthetic outcome of the procedure (Table 2 ). Five-Point Likert Scale to Assess Aesthetic Outcome All statistical analyses were performed using Prism 9 (GraphPad Software, Inc., San Digo, CA) and Microsoft Office Excel (Microsoft Corp, Redmond, WA). Data are expressed as mean ± SD. For comparisons of means between different groups, a statistical difference was determined using a paired t test; an alpha value of P < 0.05 was considered statistically significant. Categorical variables were analyzed using analysis of variance to assess associations, providing a detailed comparison alongside continuous data analysis. The study was conducted by globally accepted standards of Good Clinical Practice (ICH-E6), the European Directive 2001/20/EC, and the revised version of the Declaration of Helsinki set out in the European Directive. The study was conducted in accordance with the French MR004 methodology for medical research. In accordance with the ethical standards, this observational study did not modify existing diagnostic or therapeutic strategies; however, patients were informed of their inclusion in the study.

A cohort of 191 female patients diagnosed with type 3 lipedema affecting the lower limbs were included in this analysis. The demographic characteristics of the study participants are presented in Table 3 . The average age at the time of the initial surgery was 38.5 ± 10.5 years, with a mean BMI of 26.8 ± 4 kg/m 2 . Among them, 23 patients (12.04%) were classified at stage 1 of lipedema, 56 patients (29.31%) at stage 2, and 112 patients (58.63%) at stage 3. Demographic Characteristics of the Study Participants ( n = 191) The average (SD) operative time was 151 ± 48.29 minutes, indicating some variability in the duration of the procedures. The average duration of hospitalization was 3.2 ± 1.6 days. On average, 6 ± 1.6 liters of lipoaspirate was harvested during each operation, for a total average of 9% ± 1.4% of fat aspirated compared with body weight. The average decrease in hemoglobin was −2.781 ± 1.397 g/dL. ( See Figure, Supplemental Digital Content 2 , which shows mean rate of hemoglobin before and after surgery. The average decrease in hemoglobin was −2.781 ± 1.397 g/dL. The blood transfusion rate was 4.18%, with 8 of 191 patients receiving a single transfusion of 2 units of packed red blood cells, https://links.lww.com/PRS/I56 .) The blood transfusion rate was 3.14%, with 6 of 191 patients receiving a single transfusion of 2 units of packed red blood. The time required to correct anemia depends on various factors. However, it is known that iron supplementation can increase hemoglobin levels within a few weeks, whereas recovery without supplementation typically takes between 4 and 6 months. Some authors recommend a 6-month interval between massive liposuction procedures. 43 Table 4 presents the mean VAS scores before and 12 months after the global surgical treatment for various pain-related questions. The results indicate a significant decrease in pain levels, sensitivity to touch or pressure, bruising, sensation of warmth, coldness in legs, swelling, and muscle cramps after liposuction compared with before liposuction (all P < 0.0001). VAS Score before and 12 Months after Surgical Treatment P < 0.001. Preoperative and postoperative circumference measurements of various aspirated zones are presented in Table 5 . A paired t test revealed statistically significant differences in circumference measurements for all aspirated zones postoperatively compared with preoperative values (all P < 0.001). These findings demonstrate a significant reduction in circumferences following liposuction across all measured areas. The average total circumference reduction across all zones was −6.396 cm (range, −9.268 to −3.523 cm), indicating a significant reduction in circumferences following liposuction ( P < 0.001). Mean Circumference of Various Body Zones before and 12 Months after Surgical Treatment P < 0.001. Of the 191 patients enrolled in the study, 143 (74.86%) experienced an uneventful postoperative course without complications. Eight patients (4.18%) required blood transfusions within the initial postoperative week because of severe anemia. The incidence rates of seromas, nonnecrotizing dermohypodermitis, and skin necrosis were consistent with the data reported in Table 6 . Furthermore, only 14 patients (7.32%) required a third corrective or touch-up surgery because of issues such as asymmetry or dissatisfaction with the cosmetic outcome. Incidence of Postoperative Complications in 191 Patients after Surgical Treatment After 12 months of surgical treatment, the satisfaction levels regarding aesthetic outcomes were assessed using a 5-point Likert scale. The results revealed that 52.23% of participants reported being very satisfied, followed by 37.58% who were satisfied. A minority of participants, 10.19%, indicated feeling neither dissatisfied nor satisfied, whereas no participants reported feeling dissatisfied or very dissatisfied.

Since its introduction by Illouz 44 and subsequent refinements, including the tumescent technique pioneered by Klein in the late 1980s, 39 suction-assisted liposuction has undergone significant evolution and emerged as one of the most sought-after procedures in plastic surgery worldwide. Enhanced safety measures, including lymphatic-sparing techniques 40 and advancements in lipoassisted devices, 28 , 45 , 46 have contributed to the improved safety profile of liposuction procedures on the lower limbs. The rising demand for body contouring procedures has led to advancements in efficacy, particularly in achieving desirable cosmetic outcomes. This has been facilitated by the integration of skin-tightening technologies with liposuction techniques, exemplified by modalities such as power-assisted liposuction, WAL, UAL, laser-assisted liposuction, and radiofrequency-assisted liposuction. 35 , 37 , 45 – 61 Currently, lymphatic-sparing liposuction is well documented as a viable treatment option for managing lipedema, often used after initial therapeutic interventions. Our prospective study aimed to assess the efficacy and safety of UAL VASER in treating type 3 lower limb lipedema. This investigation was prompted by the increasing demands from patients for cosmetic enhancements, emphasizing the need for procedures that offer both effectiveness and aesthetic satisfaction. When comparing WAL and TAL to UAL, several advantages and disadvantages emerge. WAL and TAL are gentler, causing less trauma to surrounding tissues, which reduces bruising and swelling. They also allow for more controlled fat removal, potentially improving aesthetic outcomes. However, these techniques may struggle with larger volumes of fat compared with UAL. UAL uses ultrasound technology to emulsify fat, enabling the removal of larger quantities, especially in fibrous areas. However, it can cause more thermal damage to nearby tissues, leading to longer recovery times and a higher risk of complications. The newer third-generation VASER technology has reduced complications. Ultimately, the choice of technique depends on the patient’s needs and the surgeon’s expertise. In our investigation, we observed a significant reduction in lipedema symptoms overall following UAL VASER treatment in 2 lower limb areas combined with adjunctive conservative measures including manual lymphatic drainage, compression garments, exercise, and dietary interventions. These outcomes align with findings from prior research using the WAL procedure, as demonstrated by studies conducted by Schmeller et al. 21 and Rapprich et al., 18 the long-term investigations by Baumgartner et al., 17 , 62 and the work of Dadras et al. 13 Carballeira Braña and Poveda Castillo, 63 reported an enhancement in symptom reduction after lipedema surgery from 30% to 40.6% when conservative treatment was incorporated both before and after the surgical intervention. This observation influenced our strategy to integrate conservative treatment both before and after surgery. Our study showed a high level of satisfaction with cosmetic results and gratitude among participants, and advocate for lymphatic-sparing liposuction combined with advanced skin-tightening technologies such as UAL VASER, following the consensus-based recommendations for VASER UAL. 28 This approach can enhance aesthetic outcomes for patients with lipedema. Unfortunately, we did not measure objective assessments of cellulitis reduction or skin quality, particularly laxity, before and after surgery. Our findings indicate a favorable safety profile for calf surgery, with most patients experiencing an uneventful postoperative course. Although complications were noted, severe cases requiring further intervention were rare. The most common issue was transient hyperpigmentation, which required no treatment, although some patients needed a third corrective operation. Skin necrosis was observed, typically a concern for aesthetic and functional outcomes. However, patients with skin necrosis reported satisfaction at the 12-month follow-up, with none requiring skin grafts (Fig. 5 ). Postoperative complications. Skin necrosis necessitating rehospitalization and débridement ( left ). Skin sequelae at 12 months without skin graft ( right ). Literature indicates that older UAL generations commonly report complications such as seromas, burns, and hyperpigmentation because of excessive energy use. 26 The reduced incidence of these issues with third-generation VASER technology can be attributed to optimized energy application through grooved probes and pulsed energy. We used 5-ring probes and operated at 60% power to minimize complications, corroborating previous studies. 27 Consistent with the consensus-based recommendations for VASER UAL, 28 the pulsed mode was favored over the continuous mode. Compared with traditional liposuction, adverse effects associated with VASER UAL are milder and of shorter duration. 28 Significant blood loss after VASER UAL is rare, contributing to the low need for blood supplementation. 28 Our postsurgery protocol focused on preventing seroma formation, implementing CDT for 6 months. These positive outcomes were also linked to careful patient selection, with higher hemoglobin levels and lower BMI, 7 and the exclusion of smokers. Integrating a comprehensive medical protocol for lipedema management with the latest lymphatic-sparing UAL VASER in 2-stage procedures shows promise. Long-term follow-up studies are essential to confirm sustained efficacy and explore the technique’s potential to reduce the need for lower limb-lifting procedures, enhancing treatment modalities for lipedema management.

The authors have no financial relationships or conflicts of interest to disclose.

SOLTA funded the open access of this article.